Provider Demographics
NPI:1205001138
Name:NYSARC INC
Entity Type:Organization
Organization Name:NYSARC INC
Other - Org Name:MONROE COUNTY CHAPTER DT FAIRPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-672-2233
Mailing Address - Street 1:1000 ELMWOOD AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3042
Mailing Address - Country:US
Mailing Address - Phone:585-271-0660
Mailing Address - Fax:
Practice Address - Street 1:1387 FAIRPORT RD
Practice Address - Street 2:BUILDING 1100
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-2003
Practice Address - Country:US
Practice Address - Phone:585-641-0304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7014305261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02287938Medicaid